Provider Demographics
NPI:1316503691
Name:GAULT, JESSICA ANN MARIE (DC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN MARIE
Last Name:GAULT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 W B AVE
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:KS
Mailing Address - Zip Code:67068-1309
Mailing Address - Country:US
Mailing Address - Phone:620-491-2418
Mailing Address - Fax:
Practice Address - Street 1:136 W B AVE
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:KS
Practice Address - Zip Code:67068-1309
Practice Address - Country:US
Practice Address - Phone:316-249-3174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05943111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor